However, unstable fractures are not always so obvious. As in three of the above cases, recognizing the instability of some fractures can be quite subtle.

The ED challenge in managing pediatric distal radius fractures lies not so much with the common simple dorsal buckle fracture since it does not require specific immobilization or with the significantly angulated fracture that clearly needs reduction. Rather, the challenge lies in recognizing the subtle fractures that may shift, identifying the direction they may shift, and ensuring proper ED immobilization and follow-up.

About 10 percent of injuries diagnosed by emergency physicians as simple buckle fractures of the distal radius are subtle examples of more complex injuries.¹ Subtle radiologic abnormalities result in significantly different ED management. Recognition requires astute radiographic interpretation.

Injury Patterns

Simple dorsal buckle fractures of the distal radius are very common. They are caused by a compression-type force applied to relatively soft, immature bone. The child falls on the outstretched hand. The volar aspect of the distal radius impacts the ground, and the force results in the commonly seen buckle fracture on the opposite compressed dorsal aspect of the distal radius.

Simple dorsal buckle fractures can be subtle on the lateral view—but the fracture line does not extend to the volar cortex and there is no angulation (the planes of the proximal and distal fragments are parallel/anatomic). Case 2 is such an example. Simple dorsal buckle fractures are stable injuries that require treatment for comfort and protection. Numerous studies have shown simple buckle fractures do well with removable splints or soft bandages.^2–9 Treating with a circumferential cast is no better for patients and often less preferred by them.^5–9 Practically speaking, in our emergency department, treatment would either be a removable premade Velcro forearm splint or a removable slab. (Fiberglass is preferred over plaster since it’s lighter and molding is not required for simple dorsal buckle fractures.) Follow-up should be arranged for proper guidance and return-to-sports advice. Typically, that would take place in the fracture clinic in a week or two. Depending on practice location and referral patterns, primary care physicians can certainly be an option for the follow-up of simple dorsal buckle fractures of the distal radius.^1,10

Occasionally, a buckle is seen, but on closer inspection, the X-ray reveals a more significant fracture type. If a greater force is applied to the volar side (ie, fall at greater speed or from height, like monkey bars), then a more significant fracture may occur, one that extends across both the dorsal and volar cortices (see Case 1). In some cases, the fracture line may not clearly extend to the volar side, but the distal fragment is mildly angulated dorsally (see Case 3). These are not simple dorsal buckle fractures. They are transverse fractures (complete or bicortical).